OPEN DIALOGUE: Clients voices to be heard

1. OPEN DIALOGUE: Clients voices to be heard Jaakko Seikkula Seikkula, J. & Arnkil, TE (2006) Dialogical meetings in social networks. London: Karnac Books

2. DIALOGUE “For the word (and, consequently, for a human being) there is nothing more terrible than a lack of response” “Being heard as such is already a dialogic relation” (Bakhtin, 1975)

3. The present moment • To be present in the ”once occurring participation in being” (M.Bakhtin) • ”Neither – nor” (T. Andersen) • From explicit to implicit knowing (D. Stern, 2004) • From narratives to telling • Intersubjectivity: ”I see myself in your eyes” (M. Bakhtin)

4. “ The conversational style (….) simply follows the conversation, while the narrative and solution-focused styles often attempt to lead it. The conversational style strives to remain dialogical, while the solution-focused and narrative styles may become monological (e.g., when therapists attempt to "story" clients' lives according to a planned agenda).” • Lowe, R. (2005). Structured methods and striking moments: using question sequences in "living" ways.Family Process, 44, 65-75.

5. Polyphonic self • When the mind is thinking, it is simply talking to itself, asking questions and answering them, and saying yes or no. When it reaches a decision – which may come slowly or in sudden rush – when doubt is over and the two voices affirm the same thing, then we call that ’its judgement´. • Plato: Theatetus 189e-190a.

6. “Voices are the speaking personality, the speaking consciousness”. (Bakhtin, 1984; Wertsch, 1990) • “Voices are traces and they are activated by new events that are similar or related to the original event”. (Stiles et al., 2004)

7. Mikko Sinikka T2 Seppo • ”Horizontal polyphony” = social relations T1 Liisa

8. ”Vertical polyphony” = inner voices Mikko Sinikka T2 Seppo T1 Liisa Family therapist technician mother father mother father female spouse son male daughter memory of death Father death sister

9. Social networks • Private social relations • Collaboration across professional boundaries • ”Horizontal polyphony”

10. Origins of open dialogue • Initiated in Finnish Western Lapland since early 1980’s • Need-Adapted approach – Yrjö Alanen • Integrating systemic family therapy and psychodynamic psychotherapy • Treatment meeting 1984 • Systematic analysis of the approach since 1988 –”social action research” • Systematic family therapy training for the entire staff – since 1989

11. MAIN ELEMENTS OF OPEN DIALOGUE MEETING • Everyone participates from the outset in the meeting • All things associated with analyzing the problems, planning the treatment and decision making are discussed openly and decided while everyone present • Neither themes nor form of dialogue are planned in advance

12. MAIN ELEMENTS OF OPEN DIALOGUE MEETING • The primary aim in the meetings is not an intervention changing the family or the patient • The aim is to build up a new joint language for those experiences, which do not yet have words

13. MAIN ELEMENTS OF DIALOGUE MEETING/3 • Meeting can be conducted by one therapist or the entire team can participate in interviewing • Task for the facilitator(s) is to open the meeting with open questions; to guarantee voices becoming heard; to build up a place for reflective comments among the professionals; to conclude the meeting with definition of what have we done.

14. MAIN ELEMENTS OF A DIALOGICAL MEETING/4 • Professionals discuss openly of their own observations while the network is present • There is no specific reflective team, but the reflective conversation is taking place by changing positions from interviewing to having a dialogue • In the conversation the team tries to follow the words and language used by the network members instead of finding explanations behind the obvious behavior

15. MAIN PRINCIPLES FOR ORGANIZING OPEN DIALOGUES IN SOCIAL NETWORKS • IMMEDIATE HELP • SOCIAL NETWORK PERSPECTIVE • FLEXIBILITY AND MOBILITY • RESPONSIBILITY • PSYCHOLOGICAL CONTINUITY • TOLERANCE OF UNCERTAINTY • DIALOGICITY

16. IMMEDIATE HELP • First meeting in 24 hours • Crisis service for 24 hours • All participate from the outset • Psychotic stories are discussed in open dialogue with everyone present • The patient reaches something of the ”not-yet-said”

17. SOCIAL NETWORK PERSPECTIVE • Those who define the problem should be included into the treatment process • A joint discussion and decision on who knows about the problem, who could help and who should be invited into the treatment meeting • Family, relatives, friends, fellow workers and other authorities

18. RESBONSIBILITY AND PSYCHOLOGICAL CONTINUITY • The one who is first contacted is responsible for arranging the first meeting • The team takes charge of the whole process regardless of the place of the treatment • The meetings as often as needed • The meetings for as long period as needed • The same team both in the hospital and in the outpatient setting • Not to refer to another place

19. TOLERANCE OF UNCERTAINTY • To build up a scene for a safe enough process • To promote the psychological resources of the patient and those nearest him/her • To avoid premature decisions and treatment plans • To define open

20. DIALOGICITY • The emphasize in generating dialogue - not primarily in promoting change in the patient or in the family • New words and joint language for the experiences, which do not yet have words or language • “Listen to what the people say not to what they mean”

21. “For each theme under discussion, every individual responds to a multiplicity of voices, internally and in relation to others in the room. All these voices are in dialogue with each other. Dialogue is a mutual act, and focusing on dialogue as a form of psychotherapy changes the position of the therapists, who acts no longer as interventionists, but as participants in a mutual process of uttering and responding”. • Seikkula, J. & Trimble, D. (2005) Healing Elements of Therapeutic Conversation: Dialogue as an Embodiment of Love. Family Process 4/2005.

22. 5 years follow-up of Open Dialogue in Acute psychosisSeikkula et al. Psychotherapy Research, March 2006: 16(2),214-228) • 01.04.1992 – 31.03.1997 in Western Lapland, 72 000 inhabitants • Starting as a part of a Finnish National Integrated Treatment of Acute Psychosis –project of Need Adapted treatment • Naturalistic study – not a randomized trial • Aim 1: To increase treatment outside hospital in home settings • Aim 2: To increase knowledge of the place of medication – not to start neuroleptic drugs in the beginning of treatment but to focus on an active psychosocial treatment • N = 90 at the outset; n=80 at 2 year; n= 76 at 5 years • Follow-up interviews as learning forums

23. OPEN DIALOGUE IN ACUTE PSYCHOSIS Table 1. Charasteristics of the patients at the baseline (N=80) Male Female Total --------------------------------------------- Age (mean) 26.9 25.9 26.5 Employment status Studying 12 12 24 30 % Working 27 11 38 48 % Unemployed 7 2 9 11 % Passive 4 5 9 11 % Diagnosis (DSM-III-R) Brief psychotic episodes 12 7 19 23 % Nonspecified psychosis 8 6 15 18 % Schizophreniform psychosis 9 8 17 21 % Schizophrenia 20 10 30 38 %

24. OPEN DIALOGUE IN ACUTE PSYCHOSIS Figure 1. Means of hospital days at 2 and 5 years follow-ups 2-5 years

25. OPEN DIALOGUE IN ACUTE PSYCHOSIS Table 2. Psychotic symptoms at 5 year follow-up compared to neuroleptic medication during the first 2 years/ % Rating of symptoms Neuroleptics 0 1 2 3 4 Total ------------------------------------- Not used 85 9 3 3 0 100 Used or cont. 58 17 8 17 0 100 ------------------------------------- Total 80 10 4 6 0 100 Chi-square 5.93; df=3; p=.145 (NS)

26. OPEN DIALOGUE IN ACUTE PSYCHOSIS Table 3. Relapses compared to use of neuroleptics during the early phase of the treatment Neuroleptics Not-used Used Total/% Chi-sq. P -------------------------------------------------------- Relapses 0-2 years 0 56 7 63/ 82 8.97;3 .030 At least 1 9 5 14/ 18 Relapses 2-5 years 0 47 9 56/ 73 2.96;2 ns At least 1 16 3 19 27 ---------------------------------------------------------- Total number of relapsed cases 28%

27. COMPARISON OF 5-YEARS FOLLOW-UPS IN WESTERN LAPLAND AND STOCKHOLM ODAP Western Lapland Stockholm* 1992-1997 1991-1992 N = 72 N=71 Diagnosis: Schizophrenia 59 % 54 % Other non-affective psychosis 41 % 46 % Mean age years female 26.5 30 male 27.5 29 Hospitalization days/mean 31 110 Neuroleptic used 33 % 93 % - ongoing 17 % 75 % GAF at f-u 66 55 Disability allowance or sick leave 19 % 62 % • *Svedberg, B., Mesterton, A. & Cullberg, J. (2001). First-episode non-affective psychosis in a total urban population: a 5-year follow-up. Social Psychiatry, 36:332-337.

28. TABLE 5 Psychological status of patients at the onset of the crisis in the Poor and Good outcome groups. Poor Good Total outcome outcome Variable N=17 % N=61 % N=78 % Duration of psychotic symptoms/months before contact • - mean 7.6 2.5 3.6 • - sd 7.6 4.1 5.3 *** Duration of prodromal symptoms/months before contact • - mean 26.7 7.0 12.6 • - sd 29.4 17.0 22.8 ***

29. TABLE 6Treatment variables of the Poor and Good outcome groups during the two-year follow-up period Poor Good Total Outcome outcome Variable N=17 N=61 N=78 Hospitalization (days) • - mean 47.5 9.0 18 *** • - sd 56.0 19.2 36.3 Use of neuroleptic drugs • Not used 47.1 80.3 73.1 • Ongoing or discontinued • medication 52.9 19.7 28.9 ***

30. Open dialogues with good and poor outcomes for psychotic crisis/ Jaakko Seikkula, 2002 /Journal of Marital and Family Therapy, 28(3):263 - 274 SUMMARY Good outcome Poor outcome Interactional dominance by clients 55-57%10 – 35% Semantic dominance by clients 50-70% 40 -70% Symbolic language area in sequences 67 – 80%0 – 20% Dialogical dialogue in sequences 60 – 65%10 – 50%